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Thesis (M.Tech.: Emergency Medical Care)- Dept. of Emergency Medical Care and Rescue, Durban University of Technology, 2008. xii, 149 leaves, Appendices A-I. / Prehospital emergency medical service (EMS) data is essential for understanding the functioning of the services as well as the community's health. Being able to clearly and accurately define the patient population in terms of demographics and clinical condition may guide the EMS in resource management, clinical governance, research, education and political decisions. However, such data is limited in South Africa. This research, therefore, aimed to develop a data collection tool to determine the population of prehospital emergency medical care patients in South Africa. The objectives were: (i) determination of what data needed to be collected, (ii) development of a tool to collect the data, and (iii) testing the tool for ease and appropriateness of use and completeness of data collection in an authentic environment. A mixed-method, predominantly qualitative methodological design was used, with some elements of grounded theory. There were three phases corresponding to the objectives. The first two were qualitative and the third was both qualitative and quantitative. In the first phase expert consensus was sought, using a focus group discussion and Delphi study, to develop a minimum data set (MDS) to describe the patient population. The resultant MDS consisted of 18 data elements which could be categorised into demographics, time and location of EMS use, the clinical reasons for EMS use, and the actual use of the EMS. A tool and associated user instructions, based on the findings of Phase One, were developed and refined during Phase Two. Phase Three was used for testing the tool in an authentic environment. The tool was found to be acceptable and user-friendly. Further testing of the tool for accuracy and reliability is recommended.

Sepsis and its manifestation as a shock state in “septic shock” have long caused medical issues and death worldwide. The disease requires quick identification, diagnosis, and intervention with very high mortality rates prevalent otherwise. Historically this has been due to limited awareness of the disease and misclassification of its prevalence, severity, and incidence. Luckily in the past decade there has been increased interest and therefore resources devoted towards improving care and further understanding a disease that is one of the leading causes of mortality in hospitals worldwide. Over the past handful of years novel interventions and diagnostic techniques have become available. Unfortunately, in many cases these new discoveries have not yet trickled down to many of the providers on the frontline and a large amount of variation in care exists across the country. Because of the time sensitivity of sepsis, it is imperative that individuals working in the areas of healthcare who first come in contact with these patients have a clear understanding of the newest advances and resources available. In this thesis the goal is to first analyze the current protocols and standards of care for sepsis and then secondly consider new developments available both in the hospital and in prehospital emergency medical services (EMS). From the current information, strategies and protocols based on improvement of patient outcomes, can be streamlined and optimized moving forward. As predicted, there is currently an incredibly large amount of variation and knowledge on the subject with some areas implementing very progressive protocols while others still lack a sepsis protocol all together. In general, the current consensus in the field is that rapid identification and initiation of treatment is the most important component to long term survival. Improvement of outcomes therefore relies on standardization of protocols with incorporation of education components for healthcare providers. This aims to raise awareness and encourage utilization of the newest information and suggestions available. Increased interdisciplinary cooperation between prehospital providers in EMS and care providers in the hospital can also lead to improvement of recognition and treatment times for these patients. Future considerations were also examined that may potentially be applicable moving forward to improve these standards even further. There is a much opportunity available in each of these areas currently and progress is key to improving outcomes.

Effective teamwork has been shown to optimize patient safety. However, teamwork research in Emergency Medical Services (EMS) is sparse. Before successful interventions can be implemented, the appropriate content of such interventions should be determined. We tested the applicability of a teamwork processes framework in emergency care (Fernandez et al., 2008) to the EMS context. We recruited participants from an EMS agency in Houston, TX, using purposive sampling. Full-time employees with a valid EMT/paramedic license were eligible. Using semi-structured format, we queried respondents on task/team functions and enablers/obstacles of teamwork in EMS. Phone interviews were recorded and transcribed. Structural coding was based on our theoretical model. Through a deliberative process, we combined codes into candidate themes. Analytic memos during coding and analysis identified potential themes, which were reviewed/refined, and compared against our framework. We reached saturation once 32 respondents completed interviews. Among participants, 30 (94%) were male; the median experience was 15 years. Our analysis identified the team processes in the Marks’ Teamwork Process Model in four domains: Action, Planning, Reflection and Interpersonal Processes. Additionally, the concepts cited as being central to team effectiveness in EMS were: leadership, crew familiarity, team cohesion, interpersonal trust, shared mental models, and procedural knowledge. The revised model was useful for describing teamwork processes that providers employ to drive performance in EMS. Additionally, we identified emergent concepts that influence teamwork processes in EMS. Our findings inform our understanding of teamwork processes in EMS, and may be useful in guiding future team-based interventions tailored to EMS. / 2019-11-08T00:00:00Z

This study has used a mixed methodology to explore the impact of geographic, temporal and ambulance crew skill factors on ambulance clinicians’ decisions to leave a patient on scene after attending a 999 call. Four phases of work were undertaken using both qualitative and quantitative methods to build an understanding of the complex nature of pre-hospital clinical reasoning. A novel scale, the DMASC survey was developed, which indicated four factors influence decision-making in this context. More experienced staff scored significantly differently to other staff groups on the ‘Experience’ and ‘Patient characteristic’ subscales of the tool. Qualitative work explored these findings in more detail and five inter-related themes were identified, namely, ‘Communication’, ‘The three ‘E’s’, education, experience and exposure’, ‘System influences’, ‘Professionalism’ and ‘Patient characteristics’. The final phase of the study undertook to analyse retrospective call data from one large ambulance service over a one-year period. All of the five predictor variables, rurality, time of day, day of the week, patient condition and crew skill level, influenced the likelihood of conveyance. Of these the level of clinical skill of the first crew at scene was independently significant. The results of this work are discussed in relation to the strategic and operational context of NHS ambulance services. The thesis is structured as a series of papers yet to be submitted for publication. Although this confers a degree of repetition, it provides a logical analysis of the methods used to explore factors that may influence paramedic’s clinical decision making when deciding to leave patients at home following a 999-call attendance.

Objectives: This study has been conducted to determine the levels of inappropriate use of the A&E for conditions that could be treated by GPs, the nature of the morbidity pattern of those conditions, the reasons why primary care services were not being utilized, and also examined the validity (i.e. sensitivity and specificity) of patient classifications undertaken by nurses at the time of admission within this local context. Study design and setting: A cross sectional study was conducted over a one year period and subjects were randomly selected from four A&E departments located across the four principle geographic regions of Hong Kong by stratified, two-stage sampling. Main outcome measure: The gold standard in differentiating true emergency cases and GP cases was based on a retrospective record review conducted independently by a panel of emergency physicians. A random sub-sample of those classified as GP cases was interviewed and compared to a matched (via morbidity status) sample of primary care patients who had attended a hospitals' GOPC in order to determine factors distinguishing these two patient groups. Multiple Logistic Regression was used to distinguish the difference between GP cases and matched GOPC primary care patients on significance and odds ratios of the variables. The morbidity pattern according to ICPC was tabulated and analysed for the 'true' A&E cases and non-urgent cases. Sensitivity, specificity and positive predictive values were computed for both non-weighted and weighted conditions. Results: The level of GP cases was found to be 57% with a significant higher proportion of patients in younger age group, and late evening. The morbidity pattern of those top 10 diagnoses of non-urgent cases was very similar to the Hong Kong general practice morbidity pattern for self limiting conditions. Closure of the clinic was the main reason for GP cases attending A&E. Other major reasons were deterioration of symptoms, GPs' inability to diagnose efficiently and patients' wish to continue medical treatment in the same hospital. Affordability was the most pronounced reason for utilising the GOPC, but did not apply to the A&E GP patients. The most accurate weighted nurses' triage classification had the average sensitivity of 75%, specificity of 65.7%, and positive predictive value of 54%. The most accurate weighted patients' self-triage classification yielded a sensitivity of 43.3%, specificity of 49.2%, and a positive predictive value of 38.6%. Conclusion: The reasons for high level of utilisation of A&E services are complex and reflect problems of delivery of GP services. There is an urgent need for the GPs to set up a network system to provide out of hours services, and also for a better interfacing between primary and secondary care, and between public and private sectors, so that patients can be referred back to GPs. The design and measures chosen for this study will help provide A&E policy makers and planners with relevant information for better addressing practical solutions. / Albert Lee. / Source: Dissertation Abstracts International, Volume: 73-01, Section: B, page: . / Thesis (M.D.)--Chinese University of Hong Kong, 2004. / Includes bibliographical references (leaves 137-151). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Electronic reproduction. [Ann Arbor, MI] : ProQuest Information and Learning, [201-] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Appendix 4 in Chinese.

This study examines the visibility of moral agency in the daily work and production of healthcare in emergency medicine at an urban emergency medical center in the United States. Through detailed ethnographic research, this study investigates how the work of paramedics, nurses and physicians within their professional practice spheres of emergency medicine constantly resolve challenges that make their moral agency visible. Several themes emerge from this study by examining and closely noting how these individuals interact and express less a principled bioethical script, but instead a personal one that is or is not explained by their professional role in treating patients. This study follows the daily conversations and interactions that embody the local moral worlds of emergency medicine in paramedics, nurses and physicians and how each of these professional groups work through and around medical and patient care issues to create care. As these individuals within their professional role address challenges in emergency care, it is their interactions and conversations that make visible the moral agency of the individual healthcare worker. By examining the domain of these work lives this study investigates the ongoing and new conflicts and resolutions for the healthcare workers and how they assert moral agency; the intersubjective local moral worlds of care; use of technology to mediate care; and the structure of medicine in emergency medical care.

Thesis (Master of Emergency Medical Care)--Cape Peninsula University of Technology, 2018. / Physical injury is a major cause of premature death and disability worldwide (WHO, 2015). Mortality statistics for South Africa indicate that approximately half of all injury-related deaths were intentionally inflicted, often as a result of sharp-force injuries (Donson 2009). Cape Town is reputed to be a violent city (Nicol et al., 2014). Pre-hospital emergency care providers are often the first medical contact for injured patients. Previously, it was understood that high volume crystalloid administration would improve survival and was standardised in the management of shock (Santry & Alam 2010). However, over-administration of crystalloid fluid can cause patient harm by potentially worsening injuries and can be detrimental to a patients survival. Current evidence supports the practice of lower volume crystalloid intravenous fluid administration- permissive hypotension. Little is known about pre-hospital emergency care providers intravenous fluid management practices for penetrating injury. Injury surveillance data for victims of penetrating injury is also scarce with the majority of current data taken from mortality sources. Surveilling pre-hospital cases may yield opportunities for prevention from premature mortality and morbidity. The aim of this study is to undertake surveillance of penetrating injury and related intravenous fluid resuscitation in the pre-hospital emergency care environment. A prospective observational descriptive survey was conducted in the Cape Metropole1. Over three consecutive months, emergency care providers documented parameters related to mechanism of injury, scene vital signs, hospital vital signs, intravenous fluid resuscitation and basic patient demographic information for patients with penetrating injury. A predetermined inclusion and exclusion criteria was used to sample patients.

Emergency Medical Service (EMS) professionals are consistently exposed to a variety of traumatic events on the job, such as cases that involve the death or injury of a patient, being physically threatened, or encountering a mass casualty incident. Not surprisingly, research has found that such traumatic exposure has major implications, as it has been related to a plethora of negative strain outcomes such as posttraumatic stress (PTS) symptoms and burnout. However, at this point, research has not empirically examined the mechanisms by which these traumatic events lead to strain. Therefore, this study aims to further investigate these mechanisms by incorporating the role that emotion regulation (i.e., expressive suppression) plays in this process. Further, this study investigates various moderators in this process, including one individual difference factor (i.e., implicit theories about emotion expression) and two contextual factors (i.e., social support and organizational constraints). To test the links in the aforementioned process, a weekly diary study was conducted online with 200 current EMS professionals. Specifically, participants completed a baseline survey (Time 0) that measured trait-level variables and demographics. Then, participants completed 10 weekly diary studies that included measures of exposure to traumatic events, negative affective reactions, expressive suppression, and strain outcomes. Multilevel structural equation modeling was used to test the study hypotheses. Results of this study show that within person, traumatic event exposure was related to strain. Further, although traumatic event exposure was not consistently related to expressive suppression, the positive link between expressive suppression and strain was consistent. Additionally, organizational constraints were found to serve as a moderator in the relationship between expressive suppression and strain, such that higher organizational constraints exacerbate this relationship. Overall, these results provide a better understanding of the process that links traumatic event exposure to strain in the EMS profession. This research has implications for organizations, as it examines various factors that may be addressed in order to ensure that EMS professionals are better equipped to deal with these unfortunate exposures. Ultimately, the results of this study will hopefully prove helpful in devising interventions to enhance the wellbeing of EMS professionals in the wake of exposure to traumatic events.